Nokea
You're caring for a patient with pneumonia. The patient has just started treatment for pneumonia and is still experiencing hypoxemia. You know that respiratory acidosis is very common with patients with pneumonia. Which arterial blood gases below represent respiratory acidosis that is NOT compensated?
- A. pH 7.29, PaCO2 55, HCO3 23, PO2 85
- B. pH 7.48, PaCO2 35, HCO3 22, PO2 85
- C. pH 7.20, PaCO2 20, HCO3 28, PO2 85
- D. pH 7.55, PaCO 63, HCO3 19, PO2 85
Correct Answer: A
Rationale: Respiratory acidosis is characterized by low pH (<7.35) and high PaCO2 (>45). Option A (pH 7.29, PaCO2 55, HCO3 23) shows uncompensated respiratory acidosis, as HCO3 is normal, indicating no renal compensation. Other options show normal pH, respiratory alkalosis, or invalid data.
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The wife of a client with active tuberculosis has a positive skin test for tuberculosis. She is to be started on prophylactic drug therapy. What drug is the drug of choice for prophylaxis of tuberculosis?
- A. Streptomycin
- B. Para-aminosalicylic (PAS) acid
- C. Isoniazid (INH)
- D. Ethambutol (Myambutol)
Correct Answer: C
Rationale: Isoniazid is the drug of choice for tuberculosis prophylaxis due to its effectiveness in preventing active disease.
The male client has had a radial neck dissection for cancer of the larynx. Which action by the client indicates a disturbance in body image?
- A. The client requests a consultation by the speech therapist.
- B. The client has a towel placed over the mirror.
- C. The client is attempting to shave himself.
- D. The client practices neck and shoulder exercises.
Correct Answer: B
Rationale: Placing a towel over the mirror (choice 2) suggests the client is avoiding looking at their altered appearance due to the radical neck dissection, indicating a disturbance in body image. This surgery often results in visible changes, such as scarring or a tracheostomy, which can impact self-perception. Requesting a speech therapist (choice 1) focuses on communication, attempting to shave (choice 3) shows engagement in self-care, and practicing exercises (choice 4) indicates recovery efforts, none of which directly reflect body image issues.
Which statement best suggests that the client understands the nurse's instruction on how to handle the sputum specimen container?
- A. I should wipe the container with an alcohol swab.
- B. I must not touch the inside of the container.
- C. I cannot put the lid on the container until the container is fairly full.
Correct Answer: B
Rationale: Not touching the inside of the container prevents contamination, ensuring an accurate sputum sample.
When caring for a client with influenza, the nurse would expect to assess for which signs and symptoms of hypoxia? Select all that apply.
- A. Cough
- B. Restlessness
- C. Fever
- D. Tachypnea
- E. Use of accessory muscles to breathe
- F. Cyanosis
Correct Answer: B, D, E, F
Rationale: Hypoxia manifests as restlessness, tachypnea, use of accessory muscles, and cyanosis due to inadequate oxygen delivery to tissues.
An adult client is to have postural drainage four times a day. In developing the care plan, the nurse should schedule this for:
- A. 7 A.M.; 11 A.M.; 4 P.M.; 10 P.M.
- B. 10 A.M.; 2 P.M.; 6 P.M.; 10 P.M.
- C. 6 A.M.; 12 noon; 6 P.M.; 12 midnight
- D. 6 A.M.; 10 A.M.; 2 P.M.; 6 P.M.
Correct Answer: A
Rationale: Postural drainage should be scheduled before or between meals and close to bedtime to avoid interference with digestion and ensure effectiveness, making 7 A.M., 11 A.M., 4 P.M., and 10 P.M. the best schedule.